​ 3 Questions with Lauren Miller, MD, MJ, CHC, CMQ, MLS(ASCP)CM

Lauren J. Miller, MD, MJ, CHC, CMQ, MLS(ASCP)^CM, a third-year resident in the Department of Pathology at the University of Michigan, doesn’t see the laboratory as different from any other service line in a health system, whether outpatient clinic, procedure center, or inpatient unit. The laboratory begins providing care as soon as a patient establishes a relationship with the health system, and while in the current model the laboratory first touches the patient after evaluation and intervention have occurred, Dr. Miller envisions a healthcare model where the laboratory is included in the initial evaluation to consult on which tests or procedures will best tap into the lab’s underutilized knowledge.  

Dismantling the barriers that have isolated the laboratory from the larger healthcare landscape are top of mind for Dr. Miller—after all, the laboratory cares for more patients every day than any clinic or inpatient floor, providing guidance and driving patient care forward. Here, Dr. Miller shares her thoughts on the advances she’s embracing in pathology, the unique perspective the laboratory has on patient care, and more.  

Pathology often involves working with cutting-edge technologies and diagnostic tools. What excites you about incorporating these advancements into your daily practice?  

The demand for laboratory testing and tissue diagnosis will continue to increase with the aging of the current population. Yet, our resources are finite. We are continually asked to do more with less. Any tool that will streamline workflows or manage specimen volume should be used to the fullest potential. I view artificial intelligence more as ‘assistive intelligence.’ Interpretation of laboratory results or reviewing tissue for diagnosis comes with a lot of noise that needs to be filtered out to find the pertinent information. Technology can lift the burden of background work so laboratory staff and pathologists can do what we do best — giving patients the information they need. 

Though rooted in science, medicine is an art. Patient samples do not read the textbook or technical manual. No one case will ever be identical to another. Acquiring knowledge in pathology and actually caring for the patient are two different, but intertwined, skillsets. I see our work in the laboratory as contributing to the patient’s story and providing building blocks for the path ahead. My job as a pathologist is to make an interpretation based on the data and deliver that interpretation in a manner the patient can understand. Our diagnoses bridge the gap between the bench and the bedside.  

As a pathologist, you have a unique perspective on disease diagnosis and patient care. How do you approach the responsibility of delivering accurate and timely diagnoses, knowing they have a significant impact on patient outcomes?  

To provide the highest quality care to every patient, developing a systematic method to evaluate each case ensures each part is given the appropriate time and attention. I equate my method in anatomic pathology to being given an intact device and dismantling it to determine how it functions. For clinical pathology, I equate my method to building a puzzle with individual pieces to reach the final picture. 

In surgical pathology, I approach each case with two questions in my mind: (1) What is the diagnosis? And (2) Based on the diagnosis, what do I need to identify that will impact the grade, stage, treatment options, and prognosis for the patient? Three factors are needed for most cases: the margin status, what anatomical structures are involved, and the presence of lymphovascular and/or perineural invasion. At that point, the evaluation becomes more nuanced. Management of some diagnoses will depend on the biomarker expression profile or the underlying genetic alterations. The goal of the final report is to provide all of the necessary information in a clear and succinct manner. 

In clinical pathology, interpreting a laboratory result correctly requires correlation of multiple pieces of information. The best place to start is to verify the quality control of the instrument and any internal control included in the assay. If the controls are valid, then I can focus on the results and the patient. A final interpretation will require multiple laboratory values and an understanding of the patient’s presentation and symptoms. The two questions on my mind are: (1) Does this result make sense for the patient? And (2) What are the possible interfering substances or analytical errors that could affect the result? The goal of a clinical pathology report is consultative in nature. We provide an interpretation based on the available information and can recommend further workup when indicated. 

Pathologists often collaborate with other healthcare professionals to provide comprehensive patient care. Tell us about a situation where you effectively collaborated with colleagues from different disciplines to optimize patient management?  

A challenge faced in transfusion medicine is supplying compatible blood products to patients with rare alloantibodies. I cared for a patient who presented in critical condition after a motor vehicle collision. The patient received multiple emergency uncrossmatched units in the trauma bay and subsequently developed a hemolytic transfusion reaction. Our workup identified that this patient had an antibody against one of the most prevalent red blood cell antigens in the general population. This patient required multiple surgeries to manage the catastrophic injuries, yet the surgery team felt they could not safely perform the more complex procedures without available blood products. Through collaboration of the trauma surgery team, ICU team, hematology/oncology team, and transfusion medicine team, we developed a strategy to schedule the patient’s surgeries to align with our ability to obtain rare units, as well as a management plan in the case of emergent transfusion. Though the patient eventually did succumb to their injuries, surgical interventions were successfully provided with the support of compatible blood products.